A Harvard expert shares his Ideas on testosterone-replacement Treatment
It might be said that testosterone is the thing that makes men, guys. It gives them their characteristic deep voices, large muscles, and body and facial hair, distinguishing them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and contributes to regular erections. It also boosts the creation of red blood cells, boosts mood, and aids cognition.
As time passes, the testicular"machinery" that produces testosterone gradually becomes less effective, and testosterone levels begin to fall, by about 1 percent a year, starting in the 40s. As guys get into their 50s, 60s, and beyond, they may begin to have signs and symptoms of low testosterone like reduced sex drive and sense of vitality, erectile dysfunction, diminished energy, reduced muscle mass and bone density, and anemia. Taken together, these symptoms and signs are often referred to as hypogonadism ("hypo" meaning low working and"gonadism" speaking to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed problem, with only about 5 percent of these affected receiving treatment.
Studies have revealed that testosterone-replacement therapy can provide a wide range of advantages for men with hypogonadism, such as enhanced libido, mood, cognition, muscle mass, bone density, and red blood cell production. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men's Health Boston, specializes in treating prostate diseases and male reproductive and sexual problems. He's developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment plans he utilizes his patients, and why he thinks specialists should rethink the potential connection between testosterone-replacement therapy and prostate cancer.
Symptoms and diagnosisWhat signs and symptoms of low testosterone prompt the average man to find a physician?
As a urologist, I have a tendency to observe guys since they have sexual complaints. The main hallmark of reduced testosterone is reduced sexual desire or libido, but another can be erectile dysfunction, and any man who complains of erectile dysfunction should get his testosterone level checked. Men may experience other symptoms, such as more difficulty achieving an orgasm, less-intense orgasms, a smaller amount of fluid from ejaculation, and a feeling of numbness in the penis when they see or experience something that would normally be arousing.
The more of these symptoms there are, the more likely it is that a man has low testosterone. Many physicians tend to dismiss these"soft symptoms" as a normal part of aging, but they are often treatable and reversible by decreasing testosterone levels.
Are not those the very same symptoms that guys have when they are treated for benign prostatic hyperplasia, or BPH?
Not precisely. There are quite a few medications that may lessen sex drive, including the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. However a decrease in orgasm intensity usually does not go along with therapy for BPH. Erectile dysfunction does not ordinarily go together with it , though surely if a person has less sex drive or less attention, it is more of a challenge to get a fantastic erection.
How can you determine whether a person is a candidate for testosterone-replacement treatment?
There are two ways that we determine whether somebody has reduced testosterone. One is a blood test and the other one is by characteristic signs and symptoms, and the correlation between these two approaches is far from perfect. Generally guys with the lowest testosterone have the most symptoms and guys with highest testosterone have the least. However, there are a number of men who have low levels of testosterone in their blood and have no signs.
Looking at the biochemical amounts, The Endocrine Society* believes low testosterone to be a total testosterone level of less than 300 ng/dl, and I believe that's a reasonable guide. However, no one really agrees on a number. It is similar to diabetes, where if your fasting sugar is over a certain level, they'll say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.
| *Note: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone therapy. Watch"Endocrine Society recommendations summarized." |
Is complete testosterone the ideal thing to be measuring? Or if we are measuring something else?
Well, this is just another area of confusion and great discussion, but I don't think it's as confusing as it is apparently in the literature. When most physicians learned about testosterone in medical school, they learned about overall testosterone, or all of the testosterone in the body. However, about half of the testosterone that is circulating in the bloodstream isn't readily available to the cells.
The available portion of total testosterone is known as free testosterone, and it's readily available to cells. Nearly every lab has a blood test to measure free testosterone. Though it's only a little portion of the total, the free testosterone level is a fairly good indicator of low testosterone. It is not perfect, but the significance is greater than with testosterone.
This professional organization urges testosterone therapy for men who have
- Reduced levels of testosterone in the blood (less than 300 ng/dl)
- symptoms of low testosterone.
Therapy is not Suggested for men who have
- Breast or prostate cancer
- a nodule on the prostate that can be felt during a DRE
- that a PSA greater than 3 ng/ml without additional evaluation
- that a hematocrit greater than 50 percent or thick, viscous blood
- untreated obstructive sleep apnea
- severe lower urinary tract symptoms
- class III you can look here or IV heart failure.
Do time daily, diet, or other factors influence testosterone levels?
For years, the recommendation has been to receive a testosterone value early in the morning since levels start to fall after 10 or even 11 a.m.. But the information behind that recommendation were drawn from healthy young men. Two recent studies demonstrated little change in blood testosterone levels in men 40 and older within the course of this day. One reported no change in average testosterone till after 2 Between 6 and 2 p.m., it went down by 13 percent, a modest sum, and probably insufficient to influence diagnosis. Most guidelines nevertheless say it's important to do the evaluation in the morning, however for men 40 and above, it probably does not matter much, provided that they get their blood drawn before 5 or 6 p.m.
There are a number of rather interesting findings about diet. For instance, it seems that individuals who have a diet low in protein have lower testosterone levels than men who eat more protein. But diet has not been studied thoroughly enough to make any recommendations that are clear.
Exogenous vs. endogenous testosterone
Within the following guide, testosterone-replacement therapy refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Based on the formulation, treatment can cause skin irritation, breast tenderness and enlargement, sleep apnea, acne, decreased sperm count, increased red blood cell count, along with additional side effects.
At a recent prospective study, 36 hypogonadal men took a daily dose of clomiphene citrate for at least three months. Within four to six weeks, all of the men had heightened levels of testosterone; none reported any side effects during the year they were followed.
Because clomiphene citrate is not approved by the FDA for use in men, little information exists about the long-term effects of taking it (including the risk of developing prostate cancer) or whether it is more effective at boosting testosterone than exogenous formulations. But unlike exogenous testosterone, clomiphene citrate preserves -- and possibly enhances -- sperm production. That makes drugs like clomiphene citrate one of only a few choices for men with low testosterone who wish to father children.
What kinds of testosterone-replacement therapy are available? *
The oldest form is an injection, which we still use since it is cheap and since we reliably get good testosterone levels in nearly everybody. The disadvantage is that a person should come in every couple of weeks to get a shot. A roller-coaster effect can also occur as blood testosterone levels peak and return to baseline.
Topical therapies help preserve a more uniform amount of blood testosterone. The first form of topical therapy has been a patch, but it has a quite high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a reddish area in their skin. That limits its use.
The most widely used testosterone preparation from the United States -- and the one I start almost everyone off -- is a topical gel. The gel comes in miniature tubes or within a unique dispenser, and you rub it on your shoulders or upper arms once a day. Based on my experience, it tends to be consumed to good levels in about 80% to 85 percent of men, but that leaves a significant number who do not absorb sufficient for this to have a positive impact. [For details on several different formulations, see table below.]
Are there any drawbacks to using dyes? How long does it require them to get the job done?
Men who start using the implants need to come back in to have their testosterone levels measured again to be sure they are absorbing the right amount. Our goal is the mid to upper assortment of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood really goes up quite fast, within several doses. I usually measure it after 2 weeks, although symptoms may not change for a month or two.